CurrentKaiser PermanentePolicy N/A

Kaiser Permanente Clinical Review Criteria for Intraoperative Neurophysiologic Monitoring

Kaiser Permanente Clinical Review Criteria defining medical necessity, provider qualifications, indications, and coding for intraoperative neurophysiologic monitoring (IONM) for Kaiser Foundation Health Plan of Washington members; includes covered procedures, experimental exclusions, documentation requirements, and applicable CPT/HCPCS codes.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Permanente Clinical Review Criteria for Intraoperative Neurophysiologic Monitoring

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review DateApr 1, 2025

Key ActionWhen requesting IONM services, submit last 6 months of radiology (if applicable) and last 6 months of clinical notes from the requesting provider/specialist to support medical necessity.

POLICY UPDATE CHANGES

MPC approved to adopt KP National criteria for IONM on 05/07/2019.

3Required provider/billing conditions

4IONM modalities covered (SSEP, MEP, EEG, EMG)

10Examples of covered procedures (major categories)

9Procedures considered experimental/investigational

Kaiser Permanente Clinical Review Criteria define medical necessity, required provider qualifications and supervision, covered indications, coding, and documentation rules for Intraoperative Neurophysiologic Monitoring (IONM) for Kaiser Foundation Health Plan of Washington members. The policy applies to non‑Medicare and Medicare members (with Medicare subject to applicable LCD/NCD considerations) and covers modalities such as SSEP, MEP, EEG, and EMG when specified criteria are met. Overall coverage stance is mixed: IONM is covered for specific high‑risk spinal, intracranial, and vascular procedures when criteria are met, and considered experimental/investigational for many routine or unsupported indications.

Policy metadata

last_review2024-04-02

next_review2025-04-01

statusCURRENT

coverage_stancemixed

Medical-Necessity Criteria

General Provider and Billing Requirements (Non-Medicare Members)

IONM is covered when ALL of the following provider, supervision, monitoring, and billing conditions are met:

ALL of the following

Monitoring must be performed by either a licensed physician trained in clinical neurophysiology or a trained technologist practicing within scope of licensure/certification and working under direct supervision of a physician trained in neurophysiology.
Monitoring must be interpreted by a licensed physician trained in clinical neurophysiology, other than the operating surgeon, who is either in attendance in the operating suite or present by real-time remote mechanism and immediately available.
Monitoring must be conducted and interpreted real-time (on-site or remote) and continuously communicated to the surgical team.
The physician performing or supervising monitoring must be monitoring no more than three cases simultaneously.
Charges related to intraoperative monitoring will only be reimbursed when billed on a HCFA 1500 claim form for professional charges.
Charges related to intraoperative monitoring billed on a UB form are not reimbursable.

Indications: SSEP with or without MEP

SSEP (with/without MEP) may be medically necessary during the following procedures:

ONE of

Spinal procedures
Correction of scoliosis
Dorsal rhizotomy
Correction of deformity involving traction on the spinal cord
Surgery due to traumatic injury to spinal cord
Spinal cord tumor removal

Indications: EEG

Intraoperative EEG monitoring may be considered medically necessary for any of the following:

ANY of the following

Intracranial procedures (microvascular decompression, acoustic neuroma removal, cranial base lesions, vestibular neurectomy, cholesteatoma/mastoidectomy, removal of cranial nerve neuromas, deep brain stimulation, endolymphatic shunting, oval/round window graft, removal of cavernous sinus tumors, resection near motor cortex, resection of epileptogenic tissue, aneurysm repair, intracranial AVM)
Non-cranial vascular procedures including arteriography with test occlusion of carotid artery and carotid artery surgery

Indications: EMG

Intraoperative electromyographic (EMG) monitoring may be considered medically necessary when monitoring is during any of the following procedures:

ANY of the following

Dorsal rhizotomy
Microvascular decompression of cranial nerves
Cholesteatoma, including mastoidotomy or mastoidectomy
Removal of acoustic neuroma, congenital auricular lesions, or cranial base lesions
Vestibular neurectomy for Meniere's disease

Documentation Required

To support medical necessity, include ALL of the following documentation when requesting services:

ALL of the following

Last 6 months of radiology if applicable
Last 6 months of clinical notes from requesting provider and/or specialist

Not Medically Necessary / Experimental

Experimental and Investigational (Not Medically Necessary)

IONM is considered experimental/investigational for all indications not meeting above criteria, including but not limited to:

ANY of the following

Routine lumbar or cervical laminectomies and fusions
Spinal cord stimulator implantation
Cochlear implantation
Thyroid or parathyroid surgery
Vagal nerve stimulator implantation
Spinal injections
Hip replacement
Parotid gland surgery
Intraoperative monitoring of visual evoked potentials (VEP) for all indications
Motor evoked potentials using transcranial magnetic stimulation for all indications
Nerve conduction studies for intraoperative monitoring purposes for all indications

Evidence is mixed: systematic reviews and guideline statements report that IONM is sensitive and specific for detecting intraoperative neurological compromise but there is insufficient evidence that IONM use reduces the incidence or severity of postoperative neurological injury. Professional society statements (AANS/CNS and AANEM) note IONM’s diagnostic sensitivity while concluding evidence is inadequate to show outcome benefit.

Coding

General Neuromonitoring (Considered Medically Necessary when criteria met)CPT|HCPCSCovered

95940	Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure).
95941	Continuous intraoperative neurophysiology monitoring; from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure).
G0453	Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient; (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure).

Somatosensory-evoked potentials (SSEP)CPTCovered

95925	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs.
95926	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs.
95927	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in trunk or head.
95938	Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; used when both upper and lower limbs monitored.

Motor evoked potentials (MEP)CPTCovered

95928	Central motor evoked potential study (transcranial motor stimulation); upper limbs.
95929	Central motor evoked potential study (transcranial motor stimulation); lower limbs.
95939	Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.

Electroencephalography (EEG)CPTCovered

95822	Electroencephalogram (EEG); recording in coma or sleep only.
95955	Electroencephalogram (EEG) during nonintracranial surgery (eg carotid surgery).

Electromyography (EMG)CPTCovered

95860	Needle electromyography; extremity with or without related paraspinal areas.
95861	Needle electromyography; 2 extremities with or without related paraspinal areas.
95867	Needle electromyography; cranial nerve supplied muscle(s), unilateral.
95868	Needle electromyography; cranial nerve supplied muscles, bilateral.
95870	Needle electromyography; limited study of muscles in extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters.

Considered Not Medically Necessary / Experimental CodesCPTNot Covered

95907	Nerve conduction studies; 1-2 studies.
95908	Nerve conduction studies; 3-4 studies.
95909	Nerve conduction studies; 5-6 studies.
95910	Nerve conduction studies; 7-8 studies.
95911	Nerve conduction studies; 9-10 studies.
95912	Nerve conduction studies; 11-12 studies.
95913	Nerve conduction studies; 13 or more studies.
95930	Visual evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report.
95937	Neuromuscular junction testing (repetitive stimulation/paired stimuli) each nerve method.

Provider Actions

Prior Authorization

Documentation submission for medical necessity

When requesting IONM services, submit documentation to support medical necessity including the last 6 months of radiology (if applicable) and the last 6 months of clinical notes from the requesting provider and/or specialist.

Last 6 months of radiology (if applicable)
Last 6 months of clinical notes from requesting provider and/or specialist

Billing Rule

Professional billing form requirement

Reimbursement for IONM professional charges is allowed only when billed on a HCFA 1500 claim form; charges billed on a UB form are not reimbursable.

Billing Rule

Physician case-load limit

The physician performing or supervising monitoring must be monitoring no more than three cases simultaneously; claims may be disallowed if supervision exceeds this limit.

Documentation Required

Real-time interpretation and communication

Monitoring must be conducted and interpreted in real-time (either on-site or via real-time remote mechanism) and continuously communicated to the surgical team; documentation should reflect continuous monitoring and the physician’s immediate availability to the team.

Billing Rule

Coding constraints for SSEP/MEP

Do not report CPTs 95925 and 95926 together for the same procedure when both upper and lower limbs are monitored; instead use CPT 95938. Similarly, do not bill CPTs 95928 and 95929 together when both upper and lower limbs are monitored; instead use CPT 95939.

Affected SSEP codes: 95925, 95926, 95938
Affected MEP codes: 95928, 95929, 95939

Background and Evidence

IONM is intended to provide real‑time assessment of neural function during surgery to identify patients at increased risk of neurologic injury so that intraoperative corrective actions might be taken. The evidence base shows IONM can detect physiological changes and is sensitive and specific for identifying intraoperative neural compromise, but studies and society reviews report mixed results about whether intraoperative detection leads to interventions that improve postoperative neurological outcomes.

Source	Summary
Fehlings 2010
IONM is sensitive and specific for detecting neurological complications during spinal surgery; review of prospective cohort studies and no serious harms reported.
AANS/CNS 2014
Insufficient evidence that IONM reduces incidence or severity of neurological injury; may help diagnose injury intraoperatively.
AANEM 2014
Supports intraoperative SSEP for certain high-risk spinal surgeries; not indicated for routine lumbar/cervical root decompression.

Definition: Intraoperative Neurophysiologic Monitoring (IONM) — real‑time monitoring of neural function during surgery using modalities such as somatosensory‑evoked potentials (SSEP), motor‑evoked potentials (MEP), electroencephalography (EEG), electromyography (EMG), and brainstem auditory evoked responses (BAER) to detect intraoperative changes in neural pathways.

Name	Number	Type	Effective Date
Noridian Sensory Evoked Potentials & Intraoperative Neurophysiology Monitoring (retired L34072)
L34072
LCD (retired)
retired (no effective date provided)

OpenPayer

Kaiser Permanente Clinical Review Criteria for Intraoperative Neurophysiologic Monitoring

Coverage Summary

Medical-Necessity Criteria

Not Medically Necessary / Experimental

Coding

Provider Actions

Background and Evidence

Medicare Determinations

Revision History